In which Dr Aust reads the BCA’s latest press release, almost causing a beer-keyboard “critical incident”

Many sceptical bloggers have commented that the British Chiropractic Association may win their libel case against Simon Singh, but stand to lose, as the saying goes, “in the court of public opinion”. Following Singh’s announcement that he will carry on the fight, seeking leave to appeal Mr Justice Eady’s “astonishing and highly illiberal” (to quote Jack of Kent) ruling on meaning and perhaps ultimately looking to the European Court of Human Rights, the BCA seem to be getting a bit nervous.

Now, various puffs of black and white smoke emerging from Chiro-world seem to show that the campaign by bloggers to subject chiropractic’s quasi-medical claims to examination is having an impact. You can find a summary over at The Lay Scientist.

But the thing that seems to have especially rattled the BCA in the last couple of days is the campaign launched by Sense About Science:

So far, more than four thousand people have signed the statement. And the campaign has also gathered considerable media coverage (links here).

“The BCA sued Simon Singh only as an act of last resort. He published what the Association believed were libellous remarks in the Guardian. He could have retracted the remarks and apologised and the debate would have continued away from the legal world. He chose not to do so. The case against Simon Singh has been re-characterised by his supporters as a freedom of speech issue. It is not. The law of libel is about the proper censuring of individuals’ ability to publish false and defamatory material that causes damage to reputation. To stifle scientific debate would clearly be wrong. The BCA is fully supportive of scientific debate and this should be a fundamental right. However, with rights come responsibility and scientists must realise that they cannot simply publish with impunity what they know to be untrue and libellous”.

Now, that sounds to me like they are getting worried that, while they won the first battle, they are losing the war.

The sentences that will cause a laugh amongst any scientists following the Singh case, and certainly nearly caused me to choke on my post-prandial beer, are:

“To stifle scientific debate would clearly be wrong. The BCA is fully supportive of scientific debate and this should be a fundamental right”

Following which I had a fleeting vision of His Holiness the Pope renouncing Catholicism and signing up as a snake-handling Evangelical preacher.

Why do I find the BCA’s claims about being “fully supportive of scientific debate” a bit hard to swallow? Well, consider first the following history of the libel action, given by Simon Singh in his online essay about the case:

“Initially The Guardian newspaper tried its best to settle the matter out of court by making what seemed to be a very generous offer. There was an opportunity for the BCA to write a 500 word response to my article to be published in The Guardian, allowing the BCA to present its evidence. There was also the offer of a clarification in the “Corrections and Clarifications” column, which would have pointed out: “The British Chiropractic have told us they have substantial evidence supporting the claim they make on their website that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying. (Beware the spinal trap, page 26, April 19).”

Unfortunately, the BCA rejected these offers and moreover made it absolutely clear that it was not suing The Guardian, but rather it was suing me personally.”

More recently, there has been much speculation about this evidence the BCA are harping on about. Not surprisingly, really, since that is how scientific arguments are constructed, by setting out and then interpreting the evidence.

Now, we know the outline of what Simon Singh sees as the key scientific evidence regarding the claims made in the BCA’s leaflet Happy Families, because it is set out in the particulars of his defence, filed back in the Autumn and extensively summarised on Jack of Kent’s blog.

In contrast, we still know little of what the BCA thinks about the science – or even what science it is thinking about. The disputed Happy Families leaflet is gone from their website. As far as I am aware, the BCA has not released the list of the “27 different publicly-available research papers” that their press release of May 26th made a great play of. These are the papers that they were demanding to know whether Simon Singh had read before he wrote his Guardian article.

As many others have asked, can we see this list of (published) evidence? Please? Pretty please? That would be a start, at least. It seems bizarre to me that, nearly ten months after Singh and the Guardian made their offer of a forum to air the evidence, we still don’t know what this “plethora” of literature is that the BCA find so convincing. It deserves emphasis that this was so conclusive in their minds that they stated (more than a touch pompously, if you ask me):

“If Dr. Singh had read the research he could not have held the view he expressed in the Guardian unless he simply chose to ignore the facts.”

Hmm. To state the blindingly obvious, again: it is hard to argue about the merits, or otherwise, of scientific evidence, if we don’t know what it is.

Which reminds me of a well-used and very apt phrase:

“Show us your evidence. Not your legal muscle”

So:

Dear BCA. Show. Us. The. Evidence. Please.

If, that is, you have any that stands up.

Now, something else occurs to me too. The BCA have presumably worded this latest statement carefully, with the advice of their lawyers (kerr-chinng). But I do wonder about the implication, taken together, of the following sentences:

“[Singh] published what the Association believed were libellous remarks”

“The law of libel is about the proper censuring of individuals’ ability to publish false and defamatory material that causes damage to reputation.”

“..with rights come responsibility and scientists must realise that they cannot simply publish with impunity what they know to be untrue and libellous”

Now, though the last sentence says “scientists”, it seems to me that a reasonable person would be likely to draw the inference that the BCA is referring in this sentence, not merely to scientists in general, but to Simon Singh in particular. After all, their dispute with him is the subject of this press release, and they state clearly that they believe his published remarks were libellous.

Anyway, to press this point, consider if I were to amend the final sentence to:

“with rights come responsibility and scientists, like Simon Singh in this case, must realise that they cannot simply publish with impunity what they know to be untrue and libellous”

Now, in this amended sentence, which I would contend is what most people would take the BCA’s original sentence to mean, Singh would be being accused of publishing something whilst knowing it to be untrue. Publishing, in effect, a bogus statement.

Which, as I recall, is exactly what Mr Justice Eady has insisted Singh accused the BCA of doing by using the B-word.

Anyway, I would have thought this would be a clearly defamatory statement about Simon Singh, liable to cause grievous damage to his reputation and good name.

Now, it may be that my legal understanding is incorrect here – in which case I await Jack of Kent coming by to put me right. Or alternatively, and perhaps more likely, this may be already “subsumed” in the existing action by the BCA against Singh.

I do hope that the evidence they refer to is more impressive than the citations on the BCA’s own research page: I took a look and was not impressed by the quality of the evidence they cited. I asked several questions of the BCA and my latest email to them has gone unanswered (it’s been 9 days since I sent it). I think perhaps another blog post on the BCA is called for.

Quite, Neuro. We sceptics tend to repeat about Alt.Reality therapies and therapists that they either:

(i) start squarely from a standpoint of belief (like homeopathy); or (if one is being ultra-charitable)

(ii) vaguely resemble medicine before it properly took on board the idea that one’s “intuition” and “experience” was not in and of itself enough to be sure that one was right.

But the inability to engage with self-critique is absolutely central to almost all the CAM folk. Again and again one comes away seeing that the underlying philosophy is:

“We KNOW this works, because we see it work and we can’t possibly be fooling ourselves. So all the evidence that agrees with us that it works is right, and all the evidence that doesn’t agree is wrong.”

A corollary of the above is:

“People who keep arguing that the evidence we therapists KNOW is wrong (that is, all the stuff that says CAM therapies are ineffective) is correct MUST be fools, knaves, reactionaries, pharma shills etc etc.”

Did you notice how George Lewith labelled David Allen Green “a prominent member of the anti-CAM brigade” in a letter to the New Scientist? And Lewith is practically UK CAM apologism’s leading academic intellectual – Professor at a Russell Group University etc. etc.

David has written about the legal aspects of the Singh case – he never mentioned chiropractic before that – and once about the deluded Jeremy Sherr and whether what Sherr was doing in Tanzania might be illegal. But from Lewith’s POV, if someone writes about a pattern of CAM people resorting to law, then that person must be a “member of the anti-CAM brigade”.

As a layman on such matters, the proverbial “man on the Clapham omnibus”, it has become transparently plain to me that the officers of the BCA know, and must have always known, that those contentious claims* of efficacy of chiroquacktic that were publicly made by their association are, in fact, bogus**.
Vis: without factual support.
For if they had such, they surely would have grandly presented it by now?

Yes, you would think that they would have revealed their coruscating cornucopia of high-class published medical/scientific evidence by now, wouldn’t you?

The likely resolution of this, of course, is the standard one that applies to tests of placebo remedies. That is, the more the studies rely on anecdotal evidence (“This worked for me”), have no control group, don’t randomize the participants to control and treatment groups properly, don’t have any “blinding” of those doing the scoring… the more the studies say “it works”.

Conversely, the more systematically you eliminate biases, and self-deception-proof the experimental design, the more the studies say “it doesn’t work”.

This has been the pattern with pretty much every CAM therapy ever subjected to testing, from homeopathy to Reiki to chiropractic to acupuncture.

So chiropractors are always going to be able to find some published papers to support their predetermined viewpoint that chiropractic works for just about everything. It is just that they will likely be the less reliable and more flawed papers. For instance, suppose you were to run a survey of all the chiropractors who use chiropractic to treat colic in infants and ask:

“Do you do this?

If so, do you think it works?

Please tell us some heart-warming case stories if you answered “yes””

Now, a paper like this could well be in the literature somewhere, probably in a specialist chiropractic journal where it will have been “peer reviewed” – note the inverted commas – by other chiropractors. But in view of all the inbuilt biases in it, such a paper would have a “scientific evidence value” of next to bugger all.

So…the BCA can puff on about the “magic 27″ list, but of course once they actually put it out there, the papers on it will be rapidly analysed (or dismantled, if you prefer) by a multitude of scientists.

Mojo: yes, that’s a good line. The slightly more lawyer-speak version I remember was:

“Any competent lawyer can tell you if you have a case for libel.

A good libel lawyer can also tell you whether you should actually bring it”

It sort of reminds me of a famous old saying about surgery, which I remember hearing in a conference once from a well-known Professor of Plastic Surgery:

“A competent surgeon knows HOW to operate.

A good surgeon knows how and WHEN to operate

A really good surgeon knows how to operate, when to operate – and also when NOT to operate.”

Nash: Dead right about the books. If everyone who was tempted by complementary medicine, but didn’t know much about it, were to buy and read two books, the late John Diamond’s Snake Oil and Singh and Ernst’s Trick or Treatment – £ 12.28 the pair – then I reckon we could save everyone a lot of wasted time and money. It would be bad news for the CAM therapists, though.

draust: Alternatively people could check their local Library, to read them for free. Snake Oil is available in our local area, and they have several copies on the shelves. Trick or Treatment is not yet on the shelves, but there are five copies on order at various branches. I have reserved a copy of the latter: no excuse now for me not reading it!

[…] problems for people wishing to raise important issues which put them in conflict with others. As Dr Aust points out, in Simon Singh’s Story So Far article, the BCA chose to turn down a chance to respond in the […]

29 papers! It seems the affair is enough serious, because the court can accept these papers as a serious evidence. The court is incompetent in medicine, statistics and life science.
The counterstroke is necessary…

[…] A spokesman for the popular dinosaur and family favourite assured Dr Aust that “sales of T. rex soft toys and other branded merchandise have not been damaged” and that “movie tie-ins are not in danger”, but also said that the dinosaur was “looking into” the question of defending its reputation, if necessary through legal action. Reading a prepared statement, the spokesman added: […]

As the ‘splenically outraged NZ chiropractor” you refer to on DC’s blog “Mea Culpa” I find it amusing that people still exist that are naive enough to think that everything posted on a blog site would be a full and accurate portrayal of events and not perhaps tinged by the bloggers own agenda.
Don’t you think its a bit odd that, if events unfolded as described in the aforementioned blog, Prof Frizell thought my letter to the NZMJ needed to be published and felt compelled to make editorial comment? He could have just published an erratum and met his editorial obligations.
If you would like the unabridged facts surrounding this case (ie the several months communications between myself and David Colqohoun which preceded my letter and which I forwarded to the NZMJ) to allow yourself to make informed comment, please contact me at koruchiro@hotmail.com.

You are more than welcome to email me the correspondence if you want – draustblog at gmail-dot-com. However, might I suggest that DC telling you he had better things to do – which I would bet is what he did – is hardly that surprising?

As he says on his blog:

“I’d found the quotation, and the reference, in Ernst’s 2005 article, The value of Chiropractic, but at the time I couldn’t find the Journal of Quality Healthcare. I did find the same article on the web.

I have often condemned the practice of citing papers without reading them (it is, of course, distressingly common), so I feel bad about this, though I had in fact read the paper in question in its web version.“ (italics mine)

So: he had read the paper, in full. And as it turned out, his original citation was 100% accurate – the paper really existed, as did the journal. Where is there any serious intent to mislead?

Perhaps David thought your tone was such that you were pursuing a personal vendetta? I note that your published NZMJ letter reads:

“This may seem pedantic but it surely reflects a serious ethical breach. Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility?”

(my italics)

As we now see, there was no “serious ethical breach”; Colquhoun did not make up the reference; and the statement was not unsupported. So you seem to be factually wrong on all counts.

The following bit of your letter reads (again, my italics):

Incidentally, at the end of the article, conflicts of interest are listed as none. As Colquhoun is a Professor of Pharmacology and much of his research funding no doubt comes from the pharmaceutical industry, how can he have no conflict of interest [with alternative therapies]?”

As David again points out, the snipe about pharma funding is a flat untruth, and one he had already publicly corrected in a BMJ e-letter when a well known media nutritionist trotted out the identical slur.

Finally, your last paragraph uses a neat verbal construction to effectively accuse David of lacking honesty. This is a serious accusation, and I don’t see any evidence for it. I also don’t believe it. David is one of the most honest and honourable people I have ever met, either in science or in any other sphere.

For the record, David has owned up to a misdemeanour – citing something that he could not lay hands on, at that precise moment, in the cited form – though the paper existed, he had read it, and the citation was subsequently proved correct.

Beyond that, I wouldn’t be surprised if he did wish he had “lanced the boil” a bit sooner, especially if “several months communications” preceded your NZMJ letter. But I don’t see that David’s not taking you very seriously, and wishing you would get lost, amounts to any ethical failing on his part. It seems a natural enough reaction in one whose sticking his head above the parapet on the topic of Alternative Medicine has brought him libel threats, harassment, malicious complaints to his employer, and an email inbox full of assorted bile.

As DC suggested to a commenter on his blog, why don’t chiropractors go the whole hog, get properly credentialled, and become evidence-based physiotherapists? I find their defence of the indefensible silly and counterproductive. Lest it needs reiterating, people become generally smarter over time, not the reverse, and therefore less prone to accept nonsense-based remedies, so persisting in nonsense-based practice is a losing strategy.

“For graduates with a relevant degree subject, there are shortened courses leading to registration as a physiotherapist.”

Now, it is an intriguing question as to whether chiropractic would be regarded as a “relevant degree subject.” On the face of it – and judging by e.g. the Anglo-European College of Chiropractic’s website – there would certainly be some shared elements, including anatomy and physiology, and biomechanics. And one might argue, “generic clinical skills”. And possibly other things too.

On the other side of the argument, chiropractic training prominently features their underlying “philosophy” of subluxation pseudoscience, and that therefore will “permeate” many (or even most) elements of their training. So it would probably take a very detailed examination of the bits of the chiropractic degrees to see which parts were relevant, and free of subluxation claptrap.

I would be interested to know if anyone has actually ever done this – i.e. retrained as a physio from having a first qualification as a chiropractor – as then one might be able to see what view the HPC and or the Chartered Society of Physiotherapy had taken on the relevance of chiropractic training.

I somehow doubt many people ever have done it, though. I suspect a major bugbear / obstacle would be that chiropractors would almost universally believe that they are better trained, smarter, and higher status than the physios – so why should they “retrain”? After all, many chiropractors, certainly in the US and to some extent in Europe too, appear to regard themself as “fully-qualified primary care providers” – that is, they think they are perfectly capable of being your first/main port of call with the healthcare system, like your family doctor/GP. Given that, I can’t see them embracing being “downgraded” (as I suspect they would see it) to the role of physios.

Another point is that chiropractors might conceivably limit a lot of their anatomy teaching/learning to the spinal column and spinal nerves. I don’t know how much anatomy of other bits they do.

Also relevant to what the medical doctor on your blog (who by the sound of it is a specialist registrar in Radiology) says is that physiotherapists, after completing the degree, would often undergo additional more specialised training to become a physio who specialises in lower back problems. And remember that physios do NOT diagnose.

One of the debates around physiotherapy for lower back pain in the NHS (at least as I understand it) has been whether people should be referred on to A.N.Other physio, or to one that specialises in lower backs. The consensus (at least among the doctors I know) currently appears to be that the latter is what you want, if possible. Another way to do this is for lower back problems to be managed by the “Multidiscipinary Team” (ugh – ghastly term), which, if it is working right, means you should be able to see back doctors / pain specialists / physios / psychotherapists / occupational therapy people etc. etc. all under one roof (or at least via one integrated service – see e.g. here).

Oh – forgot to mention the other reason I can’t envisage many chiros becoming evidence-based physiotherapists – they would make far less money.

One of my medical friends was telling me today about a patient he saw recently. My friend discovered that the patient had been seeing a chiropractor for years for low back pain, without any obvious symptom improvement. When the patient was diagnosed with irritable guts a year or so back, the chiropractor helpfully commented that he could help with that too (how very altruistic).

The patient has since been seeing the chiropractor twice a week (sic) at £ 49.99 a session. The patient probably earns about sixteen hundred pounds a month after tax, so chiropractic is eating about a quarter of his take-home pay.

A nice little earner for someone.

The patient also confided to my doctor friend that “after I see the chiropractor, everything’s usually worse for a couple of days” (!).

Let’s compare some apples and oranges here – or maybe apples and blindfolds?

I confess I know nothing of the chiropractic side of things, but here at least physio is very competitive, so much so that physio is harder to get into than med school! Also when I go for physio I have to pay $70 (Can) per session, out of my own pocket, so when I run out of money I stop going! Of course they don’t keep you coming back for years, they aim for patient independence, but there is no shortage of patients so I’m sure the physios do quite well financially too, probably better than GPs.

Private physios in the UK certainly do make good money, though I am pretty sure the ones who work for the NHS (National Health Service, our state health provider that the right wing Republicans in the States think is the work of Satan) make a lot less, and I guess it was them I was mainly thinking of. The starting salary for an NHS physio with a 3-4 yr Physiotherapy degree is about £ 21,000.

(I found the current NHS pay scales for physios here, and the entry point for a graduate is usually Grade 5).

Obviously the NHS physios can get to higher grades with experience and more responsibility, but I imagine relatively few get to the grades above £ 40,000 unless they become full-time managers.

It would be interesting to know what proportion of physios in the UK work for the NHS vs. working privately. As I remember from the few I have known it, is pretty typical to work in the NHS for a few years to gain experience and then go into private practice, either from an office or working from home.

You are right about the entry standards for Physiotherapy being tough – it is the same here in the UK. The required grades (i.e. A level / high school leaving grades) here are not terribly different from medical school. To be fair, one has to say that the Anglo-European Chiropractic College website indicates that the grades for entry to Chiro School in the UK are similar too.

The main difference with Medicine, at least in the UK, is probably that it always has a pretty in-depth application screening system, including an interview, no matter which school you apply to. I am not sure whether Physio courses do the same. (For info, most bioscience undergrad degrees in the UK do not interview candidates any more).

It is generally understood in the UK that grades are only part of what get you into Medical School. The personal statement candidates write, the “other activities” they have done – notably ones related to healthcare or caring professions – and their performance at the interview are all critical too.

The other thing that makes these arguments and comparisons a bit tricky is that grade requirements for entry are not the same as the grades the students actually arrive at University with – at least in the UK, where offers are made before the school leaving exams on the basis of predicted grades. So the minimum requirement for medical school that is on the website may be AAB (grades in the three A level / school leaving subjects). But the students usually arrive with an average of AAA or even AAAA (A in an extra 4th subject).

I’m suffering a bout of what my wife theorises may be sciatica. All I know is that it’s a condition I get once in a while, usually precipitated by awkward movement or sitting, and lasts days to a week, and is quite painful. I’ve never had it properly diagnosed and once or twice have gone to my GP for painkillers. (It surprises me he hasn’t suggested diagnostic tests.) My late father used to have similar bouts, which usually saw him take to his bed with the strongest OTC painkillers available. The painkillers, and time, usually saw improvement.

Sorry for the lengthy preamble, but thanks to my wife’s “diagnosis”, I looked sciatica up on the internet and was surprised to find how many sites — of a general medical advice kind — recommended chiropractic as a worthwhile treatment for sciatica.

Depression being another of a litany of complaints I am blessed with, it is a condition exacerbated by the fact that around here, in metropolitan Melbourne, Australia, there appears to be a chiropractor on nearly every other corner. Still, I wonder if their treatment could be any worse than the four or five SSRIs I’ve tried and found maddeningly wanting.

Yes, it never ceases to amaze me how many things they claim are miraculously alleviated by “Chiropractic Wellness”. At £ 50 a throw, naturally.

Whenever I find the proliferation of back-cracking snake-oilers winding me up, I go back and re-read H.L.Mencken’s famous broadside against them from the 20s, which always cheers me up:

“This preposterous quackery flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities…

[Chiropractic] pathology is grounded upon the doctrine that all human ills are caused by pressure of misplaced vertebrae upon the nerves which come out of the spinal cord — in other words, that every disease is the result of a pinch. This, plainly enough, is bunkum. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to a heroic pummeling by a retired piano-mover. This, obviously, is bunkum doubly damned.”